Medicaid Expansion Fight Rages on After Obamacare Repeal Fails

Republicans in Washington may be done fighting Obamacare for now. But in the states the battle rages on, especially on Medicaid.

The rapid demise of the GOP’s Obamacare repeal bill is re-energizing efforts across the country to expand Medicaid. An expansion bill in Kansas is awaiting the governor’s review after sailing through the Republican-controlled Legislature, North Carolina’s new governor is trying to push through the program and Maine voters will decide on expansion this year.

But the program remains controversial in many of the 19 mostly Republican-led states that for years shunned billions of federal dollars to cover more poor adults. Recalcitrant GOP state lawmakers who often ignored pleas from cash-strapped hospitals — and in some cases governors from their own party — are instead seeking new leeway from the Trump administration to contract their Medicaid programs, not expand them.

“If Hillary Clinton were elected, possibly we could be negotiating this bill. But that’s not the situation we are in,” said Kansas state Sen. Susan Wagle, a Republican who opposes expansion. “This is a broken program.”

However, Medicaid expansion supporters see a new opening after the collapse of the House’s deeply unpopular Obamacare repeal bill, which a large faction of GOP moderates opposed because it would have decimated coverage for millions of low-income residents.

“Kansans have asked for this,” said Kansas state Sen. Vicki Schmidt, a Republican who sponsored the expansion bill now on Gov. Sam Brownback’s desk. “I don’t believe that we can wait for D.C. I think they had an opportunity … and they didn’t take it.”

Her bill, which incorporates conservative elements featured in other red states’ expansion programs, was easily approved 25-14 in the GOP-controlled state Senate on Tuesday. However, Brownback signaled he will veto the bill.

A new wave of Medicaid expansion is unlikely to take hold across the country anytime soon. Many state Legislatures are already starting to wrap business for the year, and resistance remains strong in these 19 holdout states. That’s particularly true in Texas and Florida — the two states that would see the largest coverage gains from the program.

“We have been pretty strong in our ‘not expanding Medicaid stance’ in the state, but we are looking forward to having a block grant with as few strings or no strings as possible so we can hopefully innovate and have patient-centered health care for the first time in a very long time,” said Texas state Sen. Dawn Buckingham.

Republican governors who have repeatedly tried to push Medicaid expansion through their Legislatures don’t anticipate a new groundswell of support for the program, citing ongoing uncertainty about how the Trump administration and Congress will now approach health care.

“I don’t know that it changes my position or belief about what could be done,” said Utah Gov. Gary Herbert, who met with Trump and administration officials on Monday. “There’s still some uncertainty out there about what tomorrow’s going to bring.”

South Dakota Gov. Dennis Daugaard also won’t ask the legislature to reconsider a Medicaid expansion model he negotiated with the Obama administration two years ago. “Health care remains very much in flux,” a spokesperson said.

Under Obamacare, the federal government covered the full cost of Medicaid expansion for the first three years. Starting this year, states began paying a portion of expansion costs, and their share will eventually rise to 10 percent.

Conservative groups who’ve fought Obamacare implementation said some states may be newly emboldened to pursue expansion.

In Georgia, Gov. Nathan Deal said Monday he will negotiate a new Medicaid waiver with the Trump administration. He refused to say whether he would accept Obamacare’s Medicaid expansion, which would cover an estimated 600,000 low-income adults. Groups pushing for expansion in the state are optimistic that Deal might consider expanding. Before the election, Georgia hospitals and the state’s Chamber of Commerce circulated plans for a conservative expansion model they hoped state lawmakers could support.

Other states are facing renewed pressure to expand their programs. North Carolina Gov. Roy Cooper is still battling Republican lawmakers who sued to halt his order to expand Medicaid earlier this year. Maine voters will consider a ballot initiative in November after conservative Gov. Paul LePage vetoed expansion bills from the state legislature several times.

“We have every reason to take steps to join the other 32 states that have expanded,” said Robyn Merrill of Maine Equal Justice Partners, which helped get the initiative on the ballot. “This is still an opportunity for Maine. We have every reason to move forward at this point.”

Virginia Gov. Terry McAuliffe again this week called on his state to adopt Medicaid expansion, citing the collapse of the GOP’s health care plan. However, the Republican-controlled Legislature has routinely rejected previous requests from the Democratic governor.

In Tennessee, a handful of key state lawmakers are considering a plan to phase in Medicaid expansion to more low-income adults. State Rep. Cameron Sexton, who chairs the House’s health care committee, said Monday they will restart discussions about their plan now that Obamacare isn’t under threat of immediate repeal.

The first phase would only expand coverage to adults with serious mental health and substance abuse issues. Lawmakers in 2015 deliberated an expansion supported by Republican Gov. Bill Haslam, but the Legislature quickly tabled it.